Best Practices - Minnesota's Highest Value Hospitals

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BEST PRACTICESMINNESOTAS HIGHEST

VALUE HOSPITALS

Kyle R. Bauser

Minnesota 2020 Graduate Research Fellow

August 2009


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Table of Contents___

Executive Summary 1

Introduction 4

Minnesotas Top Ten Hospitals 6

Data & Statistical Correlations 7

Recommendations 13

Appendix 15

Acknowledgements

Thanks to Minnesota 2020 Graduate Research Fellow, Elizabeth Rich for her guidance and feedback.

Thanks to Richard C. Hoyt, Ph.D. for useful comments and suggesons while construcng this report.


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Best Practices 1

Executive Summary___________________Minnesotans dont have to sacrice health care quality in order to control costs; however, for the states

hospitals and medical centers to connue delivering high-quality health care at an ecient value relave to

the rest of the country state policymakers and health administrators must nd ways to increase the number

of well-trained, dedicated and caring primary care medical professionals. This is becoming increasingly

dicult, as general pracce physicians are becoming a scarce commodity in Minnesota and across the naon,

especially in rural counes.

This report outlines the posive outcomes and cost savings for hospitals, medical providers and insurers when

medicine is coordinated through a primary care physician using a holisc approach that encourages healthy

habits, manages chronic condions, and provides roune check-ups and immunizaons.

To that end, the report examines quality of care (measured by diagnosis outcomes, mortality rates and paent

sasfacon) and value (measured by average Medicare reimbursement for Diagnosis Related Groups adjusted

for cost of living, percentage of uncompensated care and educaonal costs) and ranked the ten best medical

centers in terms of value in Minnesota with Fairview Northland Regional Hospital coming in on top. Overall,

for the quality ranking, the margins between posions were somemes very small, indicang Minnesota

hospitals, in general, deliver high-quality health care.

Typically, smaller medical facilies that had a higher proporon of primary care physicians to specialists came

out beer in both value and quality of care. The report nds that while specialists play an important role in

treang and caring for those with advanced and acute illnesses, the United States system of medicine and the

insurance payment structure has resulted in an increasing overreliance on specialty doctors as a rst line of

defense. This has led to many of the skyrockeng costs associated with medical care.

To bale these high costs and expenses, Medicare has increased its reimbursements to hospitals that treat

high proporons of low-income paents (via disproporonate-share hospital funds). While this certainly

helps targeted hospitals, there is queson as to whether or not the help is negligible and that the distribuon

formula might not target correctly the hospitals that cater to the majority of uninsured paents. The hospitals

that ranked well in the report not only earned high quality marks, but they did so with less Medicare funding

per-paent than competors given the cost-of-living, educaonal and uncompensated care expenses each

hospital covered. If anything, these hospitals deserve more Medicare reimbursements to help compensate for

their number of uninsured paents.

Minnesota typically ranks toward the top of lists when it comes to naonal medical and health studies, coming


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2 Best Practices

in as the 4th healthiest state, according to United Health Foundaons Americas Health 2008 rankings. The

main reason Minnesotans are generally healthier is our low uninsured rate; on average more than 92 percent

of Minnesotans have some type of health coverage compared to the naons 85 percent. That means more

people are seeing primary care doctors who are prescribing preventave treatments and beer managing

illnesses like diabetes and heart disease, liming the need for extensive and more expensive specialists

procedures.

In order to connue on this trend toward high quality, ecient health care outcomes, Minnesota needs

to beer incenvize primary care posions for young medical professionals. Recently, The Journal of theAmerican Medical Associaon released a report concluding that only two percent of medical school students

planned to persue a career in general internal medicine. The lures of presge, high six gure salaries, and lack

of laborious administrave work have many young doctors connuing on toward a specializaon. By 2020, the

U.S. will be short 40,000 primary care doctors, according to the president of the American Academy of Family

Physicians. In rural Minnesota, the lack general praconers is even starker, with fewer primary care doctors

per capita than micropolitan and metropolitan counes.

While our naon is looking for ways to ensure more people receive access to medical services, cung cost

without reducing services or coverage is crucial. This report examines how that is possible both here in

Minnesota and across the country.

Key Findings

While this report concludes that higher spending does not necessarily correlate with beer quality, it

shows that increasing the primary care labor corresponds to higher value and quality of care

By taking a holisc approach to medicine, where primary care doctors encourage healthy habits, manage

chronic condions, and provide roune check-ups and immunizaons, costs can be beer controlled.

The American Academy of Family Physicians esmates that adding one primary care doctor for every20,000 people decreases the number of unexpected premature deaths by 9 percent.

98 percent of medical school students plan to seek careers in elds other than primary care because of

the extra administrave dues, lower salary and exorbitant administrave dues.

The U.S. health care system will be short 40,000 primary care doctors by 2020.

In general, hospitals that have low proporons of Medicare reimbursements to amounts of

uncompensated care, educaon costs and cost-of-living expenses, perform more favorably in the value

ranking, while hospitals that have higher proporons of primary care/family physicians compared to

specialists fair beer in the quality ranking.


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Best Practices 3

Recommendaons

Medicare and insurance companies should structure payments to encourage more preventave

medicine, wellness programs and beer treatment coordinaon to help control costs while increasing

salary and other incenves for primary care physicians.

Encourage medical students to enter primary care pracces, especially in rural areas by extending

incenve programs.

o The Minnesota Rural and Urban Physician Loan Forgiveness Program and the Minnesota State Loan

Repayment Program provide up to $17,000 and $20,000, respecvely, for students who pracce in

federally designated Health Professional Shortage Areas.

o The Naonal Health Service Corps, which covers U.S. medical students, oers up to $50,000 loan

forgiveness to primary-care providersincluding nurse praconers and generalistswho will work

in rural counes.

Nurse praconers need to play a larger role in health care reform as they have many of the same

privileges as physicians such as diagnosing paents and prescribing medicine, but cost much less.Medicare even reimburses up to 80 percent to nurse praconers of what physicians receive.

More Medicare reimbursements need to be made to hospitals with higher percentages of

uncompensated care.


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Introduction__________________________

4 Best Practices

The number of Minnesotans over the age of 65 is expected to increase 58 percent by 2020.1 This means

Minnesotas dependency on Medicare benets will connue to rise, and with Baby Boomers nearing

rerement and requiring more medical aenon, Medicare reimbursements will need to carry more weight

when it comes to paying medical bills. Addionally, public insurance has become more prevalent in Minnesota

over the past decade reliance in 2006 increased by 4.7 percent from 19992 and of all the forms of public

coverage, Medicare comprises the largest proporon (42.1 percent).

Throughout Minnesota, Medicare reimbursements have varying weights when it comes to paying medical

bills for treang condions such as heart failure, pneumonia, chronic lung disease and hip replacements.

Interesngly, a larger Medicare reimbursement for these treatments does not necessarily mean beer quality

of care. Baicker et al. (2004)3 demonstrate that quality and Medicare spending actually have a negave

relaonship, and that a $1000 increase in Medicare reimbursements per beneciary results in a drop of nearly

ten posions in overall quality ranking (p < .001).4 On the other hand, Richard Cooper (2009) has found a

posive correlaon of health care quality and total spending at the state level.5

This MN2020 report, however, does not nd a signicant correlaon between hospital quality and Medicare

spending. Aer compiling hospital quality, mortality rates, paent sasfacon and Medicare reimbursementdata from the Hospital Compare website created by the Center for Medicare and Medicaid Services (CMS), this

report nds many of the most eecve (or lower Medicare reliance with high quality) hospitals are located

outside suburban regions.

Based on two rankings quality (measured by diagnosis outcomes, mortality rates and paent sasfacon)

and value (measured by average Medicare reimbursement for Diagnosis Related Groups adjusted for cost of

living, percentage of uncompensated care and educaonal costs) and data from the Dartmouth Atlas nds:

Fairview Northland Regional Hospital in Princeton, MN came in rst place as Minnesotas most ecient

and self-reliant hospital. This is no surprise in that this hospital was the smallest of all surveyed in terms

of licensed hospital beds and tenth in the least number of discharges. Cambridge Medical Center inCambridge, MN and Bualo Hospital in Bualo, MN came in second and third, respecvely.

In general, hospitals that have low proporons of Medicare reimbursements to amounts of

uncompensated care, educaon costs and cost-of-living expenses, perform more favorably in the value

ranking, while hospitals that have higher proporons of primary care/family physicians compared to

specialists fair beer in the quality ranking.

As hospitals get larger, both in the number of staed beds and paent discharges, their ability to stay

____________________________________________________________________________________________________________1 Klug, Susan H. The Physician Work-force Shortage: A Minnesota Perspecve. 2007.

2 Health Economics Program. Distribuon of Health Insurance Coverage in Minnesota, 2006. Jan., 2009.

3 Baicker, Katherine and Amitabh Chandra. Medicare Spending, The Physician Workforce, And Beneciaries Quality of Care. Health

Aairs. April, 2004.

4 The p-value is the probability that there is no correlaon between the dependent and explanatory variables. This merits stascal

signicance when a threshold is met. In this case, the threshold is the 10% signicance level (or .10).

5 R.A Cooper, States with More Physicians Have Beer-Quality Health Care, Health Aairs, 2009, 28, no. 1.


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self-reliant deliver high proporons of uncompensated medical care and maintain quality diminishes.

For every medical specialist addion, the quality rank decreases by 1.3 posions.

Every extra physician seen reduces the overall quality rank by two posions.

Every addion of a primary care physician per 1,000 decedents, increases the value rank by 2.7

posions.

As a hospital grows by 100 beds, the value rank decreases by 2.2 posions and 2.5 posions overall.

The composion of physician sta (in terms of specialists and generalists) has a stascally signicant

relaonship with overall hospital ranking. More specically, as the composion of specialists to generalists

increases (more specialists per generalists) by 10 percent, the overall rank decreases by 1.3 posions.

Hospitals that fall in the middle of the overall ranking may have performed excellent in one category (value

or quality) but poorly in another. For example, aer adjusng Medicare reimbursements for cost-of-living

dierences, educaonal cost proporons and disproporonate shares of low-income paent expenses for each

hospital, Hennepin County Medical Center in Minneapolis ranked rst for having the lowest amount of per-beneciary Medicare reimbursements, but came in lower for quality of care. Moreover, Lakeview Memorial

Hospital in Sllwater came in rst in the quality ranking, but lower in the value ranking.


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Minnesotas Top Ten Hospitals_________

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The top ten hospitals out of 42 surveyed in Minnesota is summarized in the table below. All data was collected

from the CMS Hospital Compare website, published on June 29, 2009 and represents the last quarter in 2007

(October) through the third quarter in 2008 (September), unless otherwise specied. The quality ranking takes

into consideraon three aspects: clinical condions, mortality rates and paent sasfacon. The value ranking

considers average Medicare reimbursement payments to hospitals for several treatments. Due to the limited

observaons for certain hospitals, not every quality measure supplied by Hospital Compare was used, and the

number of Minnesota hospitals was consequently narrowed down to 42.

The average overall ranking of metropolitan hospitals in Minnesota is 21.8, 18.7 for micropolitan hospitals

and 27.7 for rural hospitals. While the sheer size of metropolitan hospitals undoubtedly contributes to these

averages, the percentage of primary care doctors within a region also has a stascally and economically

signicant relaonship with respect to overall hospital ranking. This is important because the primary health

care workforce is disproporonately located in urban areas.

The Minnesota Department of Health esmates that 70 percent of physicians in the states 46 most rural

counes pracce primary care medicine, compared to 64 percent in micropolitan counes and 48 percent in

Minnesotas metropolitan counes. Moreover, only 8 percent of Minnesotas physicians work in rural areas,

but comprise 17 percent of all family doctors. Even though rural counes have a higher percentage of primary

care doctors, micropolitan and metropolitan counes sll have higher quanes of primary care physicians per

capita than rural counes, and these gaps are widening.


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Data & Statistical Correlations_________

Best Practices 7

Quality Ranking

Of the three quality criteria (clinical condions, mortality rates and paent sasfacon), clinical condions took

into account fourteen factors ranging from the percentage of heart failure paents given an evaluaon of Le

Ventricular Systolic (LVS) Funcon to percentage of pneumonia paents given oxygenaon assessment to the

percentage of surgery paents who were given the right kind of anbioc to help prevent infecon. For the

complete measure specicaons see the Specicaons Manual for Naonal Hospital Quality.6

Mortality rates considered the 30-day mortality and readmission rate for heart failure and pneumonia paents,

which was gathered from July 2005 through June 2008. And paent sasfacon was based on the Hospital

Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The quesons therein varied

from rang the hospital on a ten-point scale to how clean the hospital room was during the hospital stay. All of

these quality measures can be seen in the Appendix.

Value Ranking

The amount of Medicare reimbursements collected by hospitals, which is updated on the Hospital Comparewebsite quarterly, is a proxy indicator designed to measure how much the state is spending on health care.

Every year, hospitals that wish to receive Medicare reimbursements for paents who are over 65 years old,

have some type of disability or have end-stage renal disease, need to comply with federal regulaons to qualify

for full reimbursement.7

There were four Medicare payment groups, or Diagnosis Related Group (DRG), that are specied for each

hospital. Medicare pays each hospital an average reimbursement for each DRG. The DRGs used in this report

were Chronic Lung Disease, Heart failure, Pneumonia and Pleurisy in Adults With Complicaons or Preexisng

Condions and Replacement of Hip, Knee or Ankle or Reaachment of Thigh, Foot or Ankle.

Hospitals are eligible to receive a higher reimbursement for a DRG for any reason outlined by the U.S.

Department of Health and Human Services; i.e., it is classied as a teaching hospital, it treats a high percentage

of low-income paents (disproporonate share), it may treat unusually expensive cases, and/or it pays its

employees more compared to the naonal average because the hospital is in a high-cost area (wage index).

Therefore, to generate appropriate comparisons among statewide hospitals, the DRG payments were

adjusted for cost of living dierences (based on county esmates), the percentage of low-income paents and

educaonal costs for each hospital.

Stascal Correlaons

Given that the margins for quality ranking posions were small in many cases, nal rankings can be deceiving.More meaningful comparisons and policy implicaons can be ascertained from the correlaon stascs

below.8

____________________________________________________________________________________________________________6 This can be seen at www.qualitynet.org.

7 If hospitals do not comply with federal regulaons on disclosing quality, sasfacon and other measures they will lose 2 percent of

Medicare reimbursements.

8All equaons hereinaer are signicant at the 8% signicance level or beer.


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Relaonship Between Quality Rank and the Number of Medical Specialists

The Dartmouth Atlas publishes data on the proporon of specialists and primary care doctors for every 1,000

decedents during the last two years of life by hospital from 2001 to 2006.9 Exhibit 1 below shows a negave

correlaon between the quality rank and number of medical specialty doctors (p < .08), implying that more

primary care doctor visits and less specialist visits correlated with a higher overall hospital quality ranking.

Specically, for every addional medical specialist the quality ranking decreases by 1.3 posions. Plausible

explanaons for this result are beer paent outcomes as a result of the primary care philosophy promong

healthy habits, managing chronic condions, giving roune checkups and immunizaons, and coordinang the

care delivered by specialists, nurses and the remaining aspects of the health care corporaons in contrast to

the role of specialists who treat already present ailments.

____________________________________________________________________________________________________________9These measures collected from the Dartmouth Atlas act as proxies for the intended variables for October 2007-September 2008.

Medicare and other insurance providers do not reward primary care doctors for this holisc approach,

but rather give preference to specialists who typically earn four to ve mes more per year than general

praconers.

The American Academy of Family Physicians esmates that adding one primary care doctor for every 20,000

people decreases the number of unexpected premature deaths by 9 percent, which also reduces the amount

of hospitalizaon and medical bills required for medical care. While the demand for primary care physicians is

increasing, supply is diminishing, as many physicians, nurses and other medical providers near rerement.


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Best Practices 9

On the other hand, older paents typically need more specialized care resulng from complex combinaons

of chronic condions. Rural residents have fewer visits10 to health care providers and receive less preventave

services, which can be aributed to longer traveling distances and fewer praccing physicians per capita.11 As

a result, rural areas oen have a higher incidence of poor health while experiencing medical complicaons

because paents do not seek treatment unl the symptoms worsen.

Relaonship Between Quality Ranking and Total Number of Physicians Seen

A surprising result of this study is that the more physicians a paent is visits, the lower quality ranking. Exhibit

2 demonstrates this relaonship (p < .067).

____________________________________________________________________________________________________________10 Agency for Healthcare Research and Technology. Health Care Disparites in Rural Areas. May, 2005.

11 Larson SL, Fleishman JA. Rural-urban dierences in usual source of care and ambulatory service use: analyses of naonal data

using Urban Inuence Codes. Med Care. July, 2003: 41(7 Suppl):III65-III74.

12 Gawande, Atul. The Cost Conundrum: What a Texas town can teach us about health care. The New Yorker, June 1, 2009.

Every extra physician a paent visits reduces the overall quality rank by two posions. The Mayos St. Marys

Hospital, for example, where physicians are paid a salary to promote cooperaon and enhance paent care

came in 7th in the quality ranking. St. Marys Hospital avoids unnecessary paent-physician interacons and

tests because the aim is to raise quality and to help doctors and other sta members work as a team, said

Atul Gawande in a recent New Yorker arcle.12


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Relaonship Between Value Rank and Number of Primary Care Doctors

Another nding was that as the number of primary doctors increases, thereby reducing the number of

specialists, medical costs decline. This relaonship can be seen in Exhibit 3 below (p < .024).

For every extra primary care physician added per 1,000 decedents, the value rank increases by 2.7 posions.

As value rankings increase, the hospitals become less reliant on Medicare spending. The obvious excepon

is HCMC (point (5.5, 1) in Exhibit 3) which is ranked rst in value and Medicare spending, which sounds

counterintuive. On an aggregate level, HCMC is the most reliant on Medicare reimbursements, but at the

paent level the opposite is true. Lake Region Healthcare Corporaon (LRHC), for example, in 2007 incurredeleven mes less uncompensated care expenses per discharge13 (the proxy for number of low income paents

treated) than HCMC. In fact, HCMC accounted for the highest amount of uncompensated care per discharge,

4.5 mes the average, but only received 1.2 mes the average Medicare reimbursement per beneciary. LRHC,

on the other hand, was less ecient than HCMC in the cost ranking, but scored eighth in overall quality.

Relaonship Between Value Rank and Number of Staed Beds

As the size of the hospital increases, reliance on Medicare reimbursements also increases (see Exhibit 4).

____________________________________________________________________________________________________________13 The uncompensated care values taken from the Minnesota Department of Health and the amount of discharges per hospital

gathered from the American Hospital Directory.


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For every addion of 100 beds, the value rank decreases by 2.2 posions (p < .016). Exacerbang larger

hospitals ability to contain costs is the magnitude of uncompensated care required. Larger hospitals tend to

cover a higher proporon of uncompensated care than smaller hospitals. This situaon is unavoidable in areas

of high populaon density and helps explain why Medicare reimbursements are greater in these localies.

Correlaon Between Overall Hospital Rank and Number of Staed Beds

Exhibit 5 demonstrates that as the number of staed beds increases, the hospital ranking decreases (p < .006).


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Every extra 100 beds corresponds to a decrease in 2.5 overall rank posions. Even aer adjusng for various

discrepancies, as a hospital becomes larger the proporons of uncompensated care per paent become larger.

Unfortunately for larger hospitals, these higher proporons are not met with equally proporoned Medicare

reimbursements. The hospitals that made the top ten list have a disnct ability to rely less on Medicare while

maintaining high quality levels.

Correlaon Between Overall Hospital Rank and Specialist/Generalist Visits

Exhibit 6 shows that as the number of specialists increases relave to the number of primary care doctors, the

overall hospital ranking decreases (p < .028).

The smaller the rao more generalists per specialists the higher the overall hospital ranking. This implies

that, not only is the delivery of care higher when there are more primary care doctors than specialists, but

also the value is higher. This might be aributed to less unnecessary tests and treatments, adding to costs, and

more preventave measures.


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Recommendations___________________

Best Practices 13

While this report outlines ten of Minnesotas outstanding hospitals, it should be noted that the margins

between the quality rankings were, in many instances, small. Minnesota has a phenomenal health care system

and the 42 hospitals surveyed are all excellent health care providers. If Minnesota wants to maintain its ranking

as the 4th healthiest state,14 several guidelines need to be considered.

First and foremost, Minnesota must address the growing shortage of primary care physicians, parcularly

in rural areas. Currently, general praconers are among the lowest compensated physicians. Also, there

has been a long-associated sgma aached to generalists among medical students as being less presgious

because of lower compensaon compared to specialists. Financial barriers resulng from medical school debt

is not the only obstacle deterring medical students from entering primary pracces. Locaon and presge are

also major characteriscs medical students consider in choosing a specialty.

A recent paper15 surveyed medical students and found that 98 percent plan to seek speciales instead of

focusing on primary care.

Mindful of this trend, the Minnesota Rural and Urban Physician Loan Forgiveness Program and the Minnesota

State Loan Repayment Program, both of which require recipients to work in areas where primary care isneeded, should be extended. These programs provide up to $17,000 and $20,000, respecvely, for students

who pracce in federally designated Health Professional Shortage Areas.16 The Naonal Health Service

Corps, which covers U.S. medical students, oers up to $50,000 loan forgiveness to primary-care providers

including nurse praconers and generalists who will work in rural counes. Nurse praconers will also

need to play a large role in health care reform as they have many of the same privileges as physicians such as

diagnosing paents and prescribing medicine, but cost much less. Medicare even reimburses up to 80 percent

of what physicians receive to nurse praconers.

Second, primary care doctors arent reimbursed enough by insurance companies, Medicaid and Medicare

for the work they provide. Insurance companies pay large amounts of money for gastric bypass surgery for

obese paents but signicantly less to provide dietary, counseling and exercise advice. Internist Elliot Fisher ofDartmouth Medical School found that paents in high-cost areas were actually less likely to receive low-cost

prevenve services, such as u and pneumonia vaccines, faced longer waits at doctor and emergency-room

visits, and were less likely to have a primary-care physician. They got more of the stu that cost more, but not

more of what they needed. Doctors need to be rewarded for performance, not quanty.17

Third, Medicare needs to reassess the disproporonate share hospital (DSH) funding formulas to ensure

facilies that bear the majority of uninsured paents are adequately reimbursed. Unless universal health care____________________________________________________________________________________________________________14Americas Health Rankings. A Call to Acon for Individuals & Their Communies. 2008 Edion.

15

Karen E. Hauer, M.D., Steven J. Durning, MD; Walter N. Kernan, MD; Mark J. Fagan, MD; Mahew Mintz, MD; Patricia S. OSullivan,EdD; Michael Bastone, MD; Thomas DeFer, MD; Michael Elnicki, MD; Heather Harrell, MD; Shalini Reddy, MD; Christy K. Boscardin,

PhD; Mark D. Schwartz, MD. Factors Associated With Medical Students Career Choices Regarding Internal Medicine.Journal of the

American Medical Associaon, 2008;300(10):1154-1164.

16By Brooks, Kathleen D. M.D., M.B.A., M.P.A., Jennifer E. Cieslak, Ed.M., Peter M. Radclie, Ph.D., and Kaia Sjogren, B.S.N., M.P.H.

candidate. Primary Care in Minnesota: An Academic Health Centers Perspecve. Clinical and Health Aairs, Minnesota Medicine,

May 2008.

17Fisher, Elliot S. M.D., M.P.H. Medical Care Is More Always Beer? The New England Journal of Medicine, October, 2003. 349;17


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is enacted on a naonal scale, the problem of uncompensated care will always persist, especially for safety-net

hospitals like HCMC.

Fourth, while this report concludes that higher spending does not necessarily correlate with beer quality,

it shows that increasing the primary care labor corresponds to higher quality. That said, more Medicare

reimbursements need to be made to hospitals with higher percentages of uncompensated care so as to

increase the number of primary care doctors. In Gawandes recent arcle, he states:

Providing health care is like building a house. The task requires experts, expensive equipment andmaterials, and a huge amount of coordinaon. Imagine that, instead of paying a contractor to pull a team

together and keep them on track, you paid an electrician for every outlet he recommends, a plumber

for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a

thousand outlets, faucets, and cabinets, at three mes the cost you expected, and the whole thing fell

apart a couple of years later? Geng the countrys best electrician on the job (he trained at Harvard,

somebody tells you) isnt going to solve this problem. Nor will changing the person who writes him the

check.

An ecient health care system requires coordinators to pull together resources in a holisc manner. Increasing

primary care doctors should not be at the expense of losing specialists. As the AAMC (Associaon of AmericanMedical Colleges) recently reported,18 medical schools are increasing their enrollment to meet higher physician

demand. But even these adjustments wont be enough. The medical system will be short over 40,000 primary

care physicians by 2020.19 It is unfortunate that in a state with such a high quality of medical care, Minnesotans

may nd it easier to obtain costly and invasive emergency care instead of the basic diagnosc care that could

have prevented it. This is why, there needs to be connued promoon of physicians praccing family medicine,

pediatrics, internal medicine, obstetrics/gynecology and psychiatry. The best we can do for our state, both

scally and preventavely is the connued promoon of physicians praccing family medicine, pediatrics,

internal medicine, obstetrics/gynecology and psychiatry. Otherwise universal coverage is unlikely as the cost of

care will not decrease to levels comparable to the top ten hospitals listed above.

____________________________________________________________________________________________________________18 The Associaon of American Medical Colleges. Medical Schools Increase Enrollment to Meet Physician Demand: Largest Entering

Class in History Includes Notable Gains by Lanos. October, 2008.

19 Kavilanz, Parija B. Family doctors: An endangered breed. As more medical students shun primary care for higher-paid speciales,

experts warn of a severe imbalance that could cripple the naons health care system. CNNMoney, July, 2009.


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Best Practices - Minnesota's Highest Value Hospitals

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